Health care providers perform myriad services in the treatment of the ill. The performance of such services is often documented in varying degrees of detail to serve various purposes. The condition and response of patients who receive health care services are also documented. For example, records are often kept in regard to each instance that service is rendered so that the course of treatment for the patient can be readily accessible if and when needed to, for example, assess the history and effectiveness of the treatment. As another example, health care professionals will periodically document the health condition of patients to gauge their progress under medical supervision or to simply assess their overall general health. As still another example, records are kept for legal purposes so that the health care provider can document that patients in their care have received proper care. There are other motivations for documenting the treatment of patients by health care providers.
The precise method of documenting rendered health care services and condition of patients during the course of treatment of patients is similar in many respects from one health care industry to the next. However, considerations of convention and necessity particular to each industry cause differences in the creation and maintenance of medical records. The home health care industry is an example.
The home health care industry plays a vital role in the treatment of persons who receive care at home or some other non-institutional setting. Typically, a nurse or other qualified health care professional will visit a patient in her home to provide some degree of care and assessment. Each visit will prompt the nurse to enter a description of services rendered for the patient, a description of the condition of the patient, and any other observations or determinations that, if documented, would potentially benefit the patient's welfare or serve some other constructive purpose. Descriptions or determinations of this kind can often serve as medical or health records of the patient.
Conventionally, access to health records has been traditionally limited. For example, too often the health care professional who renders care for the patient creates a record and retains the record without sharing the record with the home health care agency for whom the professional works. Such exclusive retention can cause administrative and accounting difficulties for an agency. Furthermore, such exclusive retention may preclude the patient, or other interested individual, from obtaining a comprehensive account of the patient's health history. Such preclusion may result in various drawbacks, varying from inconvenience to the patient, or home health care agency, to harm to the patient's welfare. It will be appreciated that an innovative technique to allow ready, yet secure, access to a patient's care history is needed.